‘ We ’ ve changed our emphasis from what ’ s good for people to successful treatment exits ,’ he said , and he had clear advice . ‘ Get them on doses that work . Suboptimal doses make things worse .’
The optimal doses were usually between 60-120mg of methadone and 12-16mg of buprenorphine . However the average doses were 46.6mg of methadone , 10.6mg of buprenorphine and 9.3mg of buprenorphine / naloxone . So why was average dosing so low ?
‘ There ’ s fear of diversion ,’ he said . But using buprenorphine as an example , 16mg was the best dose , as ‘ at this dose it blocks . It lets them engage with getting better . Choose good clinical dosing and let people choose life .’
With representatives of some of the major treatment agencies in the room , the conference was an opportunity to debate sector-led solutions .
‘ This is not a happy conversation to be having – it touches people ’ s lives every day ,’ said Karen Tyrell , Addaction ’ s executive director of external affairs . It also had a huge impact on frontline workers , and ‘ every organisation should be doing more about that ’. To reduce drug-related deaths we needed to improve penetration rates – ‘ make sure our services are easy to get into ,’ she said .
With this in mind , a panel session brought together directors from Addaction , CGL and Turning Point , together with Paul Hayes of Collective Voice , the body representing the sector ’ s major treatment agencies .
‘ We want to develop a shared statement ,’ said Hayes . ‘ We ’ re not just looking at overdoses , but excess deaths . This is a population with compromised hearts , lungs , mental health problems , who are in and out of prison and whom the rest of the population shuns .’
There were key areas to look at . These included helping service users to recognise who ’ s most vulner - able ; improving clinical interventions and NHS engage ment ; and making pathways and appointments easier .
‘ These things are difficult to navigate – God help you if you ’ re in your 40s and have had life experience that leaves you feeling compromised ,’ said Hayes . ‘ How do we make sure we have a system that has the
right balance between offering people recovery but not pushing them into it too early ? How do we engage with people who are most at risk – people outwith the treatment system ?’
‘ We want to be able to move people at risk up the system ,’ said Dr Prun Bijral of CGL . ‘ Our key workers are really pushed right now – we need to help them …. We need to have ambition . There ’ s a lack of penetration – people are not seeing our services as attractive . We need to look at the evidence base and prioritise .’
Another challenge for providers , he said was ‘ to factor in 30 per cent or 40 per cent for non attendance loss ’.
Dr David Bremner of Turning Point agreed with the need to adapt to circumstances . ‘ We have to look at what harm minisisation advice is , in the context of massively slashed budgets – people are sometimes late or angry and we have to take this into account .
Bremner wanted to see better liaison to get things done . Getting commissioners along to morbidity and mortality meetings had ‘ borne phenomenal fruit ’.
‘ We now have 100 per cent naloxone penetration ,’ he said . ‘ When there ’ s resistance to this , you have to hit it with a sledgehammer .’
Furthermore , he wanted providers to think outside of the usual competitive mindset . ‘ We need to , as a group , set industry standards , so no one is scripted without naloxone . We also need to break the “ dare to share ” attitude ,’ he said , rather than doubling up to all invest in new things from scratch .
Addaction ’ s executive director of operations , Anna Whitton , also spoke of the need to look past the competitive element . ‘ This is about putting differences to one side , this is about people dying ,’ she said . ‘ If we find the right partnerships we can make quick differences to what ’ s happening .
‘ We need to listen to service users and facilitate access to appointments , particularly early in their treatment ,’ she said . ‘ How do we make the system more responsive to people ? How can we work flexibly and smarter ?’
In Bremner ’ s view , ‘ things we ’ ve done very poorly ’ included accepting payment by results . ‘ There are people who are seen as “ not engaging ”, but they are
‘ there ’ s a key message for the workforce ... Your fundamental job is to keep people alive . Be as aspirational as you want , but keep people alive .’
Karen tYrell
engaging , such as with the pharmacist . They ’ re just not engaging with you . We need to be more clinically authoritative .’ Providers also needed to ‘ push back against CQC ’, he believed , adding ‘ I haven ’ t come across any inspection that ’ s going to stop deaths ’.
‘ I ’ m a big fan of low threshold prescribing – but try and get that past CQC now ,’ he said . ‘ It got people on and into treatment . But I believe we ’ re moving back to a more robust harm reduction model and low threshold prescribing is part of that .’
‘ There is a mood shift ,’ agreed Hayes . ‘ Harm reduction never went away but it became unfashion - able . As the drug-related deaths agenda comes to dominate , it will be easier to talk in those terms .’
‘ Some people just want a safe place to use ,’ added Bijral . ‘ We have to work with coroners and commissioners . We have to get people into treatment .’
‘ Part of shifting the balance sits within treatment services ,’ said Harry Shapiro , director of DrugWise , from the audience . ‘ Harm reduction has become quaint , or a political watchword for legalisation . But we need to bring harm reduction back into the heart of the mainstream .
‘ There ’ s a key message for the workforce ,’ concluded Karen Tyrell . ‘ Your fundamental job is to keep people alive . Be as aspirational as you want , but keep people alive .’ DDN
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